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Background: Multi-drug resistance (MDR) TB is defined as tuberculosis (TB) disease caused by a strain of
Mycobacterium tuberculosis (MTB) that was resistant to at least isoniazid and rifampicin (RIF). Emerging Multidrug-
Resistant TB is one of the major concerns of health policy and rapid detection of M. tuberculosis and detection of
RIF resistance in infected patients are essential for disease management. The aim of this study was to evaluate
patterns of RIF resistance in cases of sputum positive pulmonary TB by using GeneXpert MTB/RIF and comparing
between phenotypic and genotypic testing of RIF resistance in MTB strains of clinically suspected MDR-TB
isolated cases in western Algeria.
Methods: In this study 50 sputum positive cases of pulmonary TB who were potential MDR suspect were
included. Their sputum samples were collected and subjected to sputum smear microscopy, culture and
conventional MTB/RIF test followed by GeneXpert MTB/RIF assay.
Results: Of total 50 cases included in this study, MTB was detected in all patients (100%) by GeneXpert MTB/
RIF. However, RIFs resistance was detected in only 21 cases (42%) by GeneXpert MTB/RIF. All RIF resistant
strains detected by GeneXpert MTB/RIF were phenotypically confirmed as MDR strains. 42.85% of cases were
retreatment failure cases, retreatment cases smear positive at 4 months were 23.82%. While 19.05% of cases were
retreatment cases smear positive at diagnosis, and 14.28% patient had history of contact with MDR-TB. Sensitivity,
specificity, positive predictive value and negative predictive value of Xpert MTB/RIF to detect RIF resistance in
comparison to conventional phenotypic drug susceptibility technique were found equal to the rates of 100%, 100%,
100% and 100%, respectively.
Conclusions: GeneXpert MTB/RIF assay is efficient and reliable technique for the rapid diagnostic of TB. Its
simplicity, high sensitivity and specificity for RIF resistance detection make this technique a very attractive tool for
diagnostic of MTB and RIF resistance in MDR cases.
Keywords: Mycobacterium tuberculosis (MTB); rifampicin resistance; multi-drug resistance (MDR); GeneXpert
MTB/RIF
Submitted Mar 24, 2016. Accepted for publication Apr 06, 2016.
doi: 10.21037/atm.2016.05.09
View this article at: http://dx.doi.org/10.21037/atm.2016.05.09
Annals of Translational Medicine. All rights reserved. atm.amegroups.com Ann Transl Med 2016;4(9):168
Page 2 of 6 Guenaoui et al. Use of GeneXpert MTB/RIF
Annals of Translational Medicine. All rights reserved. atm.amegroups.com Ann Transl Med 2016;4(9):168
Annals of Translational Medicine, Vol 4, No 9 May 2016 Page 3 of 6
Table 1 Rifampicin sensitivity pattern Table 3 Prevalence of multi-drug resistant tuberculosis (MDR-TB)
Rifampicin DST
Xpert
Sex Rifampicin Rifampicin Total (%) P value RIF RIF Isoniazid MDR-TB P value
MTB/RIF
resistant (%) sensitive (%) resistant sensitive resistant
Total 21 29 21 21
(100%) (100%) (100%) (100%)
Table 2 Distribution of Rifampicin resistant cases according to
MTB, Mycobacterium tuberculosis; DST, drug susceptibility
patients category
testing; RIF, rifampicin.
Number Percentage
Category
of cases (%)
Retreatment failure 9 42.85 However, RIFs resistance was detected in only 21 cases
Retreatment cases sputum positive 5 23.82 (42%) by GeneXpert MTB/RIF. Gender distribution
at 4 months showed that 15 (71.43%) were male and 6 (28.57%) were
Contact of known MDR-TB case 4 14.28 female among RIF resistant cases (Table 1).The sex ratio
was of 2.5. The distribution according to age showed that
Sputum positive retreatment case at 3 19.05
diagnosis the majority of patients with RIF resistance belonged to age
group of 3140 years (n=10; 47.62%) followed by 2130
Total 21 100
and 4150 years with (n=4; 19.04%) for each age group and
MDR-TB, multi-drug resistant tuberculosis. 5160 years with (n=3; 14.28%).
Table 1 shows that 15 (42.9%) male out of 35 and 6
(40.0%) female out of 15 were resistant to RIF, while 20
replace the lid, and shake vigorously 1020 times. Incubate (57.1%) male out of 35 and 9 (60.0%) female out of 15 were
for 15 minutes at room temperature. At one point between 5 sensitive to it.
and 10 minutes of the incubation again shake the specimen 42.85% of cases were retreatment failure cases,
vigorously 1020 times. Samples should be liquefied with retreatment cases smear positive at 4 months were 23.82%.
no visible clumps of sputum. Particulate matter may exist While 19.05% of cases were retreatment cases smear
that is not part of the sample. At least 2 mL of processed positive at diagnosis, and 14.28% patient had history of
sample was taken with the plastic transfer pipette from contact with MDR-TB (Table 2).
the collection container to the single-use, disposable, self- Comparison of phenotypic and genotypic resistance drug
contained GeneXpert cartridge. Then it was subjected to susceptibility showed that all strains harboring mutations
GeneXpert MTB/RIF to create a test. Results were noted in rpoB were phenotypically resistant to RIF and isoniazid.
after 2 hours. Our results show that all RIF resistant strains detected by
GeneXpert MTB/RIF were phenotypically confirmed as
MDR strains (Table 3).
Results
Twenty one cases were identified as being RIF resistant
In this study, 50 clinically suspected MDR-TB cases MTB by the conventional method. On comparing this
were selected and their sputum samples were tested by with Xpert MTB/RIF; we noted a total of twenty one
phenotypic drug susceptibility methods and genotypic drug cases that are RIF resistant MTB. Sensitivity, specificity,
susceptibility methods using the test GeneXpert MTB/RIF. positive predictive value and negative predictive value of
Of total 50 cases included in this study, MTB was Xpert MTB/RIF to detect RIF resistance in comparison to
detected in all patients (100%) by GeneXpert MTB/RIF. conventional phenotypic drug susceptibility technique were
Annals of Translational Medicine. All rights reserved. atm.amegroups.com Ann Transl Med 2016;4(9):168
Page 4 of 6 Guenaoui et al. Use of GeneXpert MTB/RIF
Table 4 Performance characteristics of the Xpert MTB/RIF assay was reported in the findings of Rasaki et al. (21).
compared to drug susceptibility testing for rifampicin (RIF) There was male preponderance, 15 (71.43%) as against
DST
6 (28.57%) female; this was in concord with the work of
Ganguly et al. (6) where male subjects had prevalence of
Xpert MTB/RIF RIF RIF PPV NPV
85.71% as against 14.29% of females. Similarly, a European
resistant sensitive
study by Faustini et al. (25) observed more drug resistant
RIF resistance detected 21 0 100% TB cases among men. This disparity could be due to the
RIF resistance not 0 29 100% fact that male subjects were more exposed to risk factors of
detected TB infection.
Sensitivity 100% In the present study, the distribution according to age
Specificity 100%
showed that the majority of patients with RIF resistance
belonged to age group of 3140 years (n=10; 47.62%)
DST, drug susceptibility testing; MTB, Mycobacterium
followed by 2130 and 4150 years with (n=4; 19.04%)
tuberculosis; NPV, negative productive value; PPV, positive
productive value. for each age group. This was in concord with the study
of Thomas et al. (26). In TRC, Chennai, 70% of the drug
resistant patients were male and their mean age was 37. In
a another study done by Robert et al. (27) the age and the
found equal to the rates of 100%, 100%, 100% and 100%,
sex distribution was similar to the study of Ganguly et al. (6)
respectively (Table 4).
where maximum number of patients with RIF resistance
were male and were in the age group of 2130 years
Discussion (26.53%) followed by 3140 years (22.44%).
In our analyzed cohort, 42.85% of cases were retreatment
In this study our objectives were to use cartridge based
failure cases, Retreatment (Previously CAT II) failure cases
nucleic acid amplification testing to evaluate patterns of
were found to be 41.83% among RIF resistant in the study
RIF resistance in cases of sputum positive pulmonary TB
of Ganguly et al. (6). In a study done by Sharma et al. (28)
and to compare between phenotypic and genotypic testing
it was found that 34% of Cat- II failures were drug resistant
for resistance to RIF in MTB strains of clinically suspected which is similar to our study. A high prevalence of MDR-
MDR-TB cases. TB in Cat-II failure is not restricted to India and has
Multidrug-resistant tuberculosis (MDR-TB) is defined been documented in Vietnam (29), Thailand (30) and
as TB caused by strains of M. tuberculosis that are resistant Rowanda (31). Retreatment cases smear positive at 4 months
to at least isoniazid and RIF (15). Mono-resistance to RIF were 23.82%, this level was superior to the study of
is rare; however, 90% of RIF resistant isolates also exhibit Ganguly et al. (6) where retreatment cases smear positive
resistance to isoniazid. Therefore, the detection of RIF at 4 months found to be 8.16% among RIF resistant cases.
resistance may serve as a surrogate marker for MDR M. 19.05% of cases were retreatment cases smear positive at
tuberculosis (16). For RIF resistance detection, Xpert MTB/ diagnosis. In studies by Sharma et al. (28) and Ganguly
RIF provides accurate results and can allow rapid initiation et al. (6) drug resistance was respectively found in 20% and
of MDR-TB treatment (17). 22.44% of Retreatment cases at diagnosis which is similar
In our study, 21 (42%) were RIF resistant, while 29 to our study. Ganguly et al. (6) found only one resistant
(58%) were RIF sensitive. This is similar to that reported case (1.02%) with history of contact with MDR TB. This
by Trivedi (18) and Shah (19) where (37.3%) and (37.47%) is consistent with a study done by Singla et al. (32) in
were resistant to RIF respectively, but lower to the study which only 0.66% of contacts developed MDR-TB. This
of Chowgule who reported a very high incidence of RIF was lower than what we found in our study where 14.28%
resistance of (66.8%) (20). This level of resistance was patient presented history of contact with MDR-TB.
superior to the study of Rasaki et al. (21), Olusoji et al. (22), According to the World Health Organization (WHO)
Lawson et al. (23), Ganguly et al. (6), where (7.2%), (8.6%), 650,000 people are infected worldwide and 12 million
(19%), (29.87%) isolates were resistance to RIF respectively suffer from TB. In Africa, 1.9% of new cases and 9.4%
and Idigbe et al. (24) who reported only 2% of resistance to of diagnosed and treated patients are infected by MDR
RIF in Lagos, Nigeria. However, no strain of RIF resistant strain (2). The results of this study showed that all strains
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